American journal of obstetrics and gynecology最新文献

Objective: To determine whether serum anti-Müllerian hormone measurement can be used as a diagnostic marker for polycystic ovary syndrome (PCOS) compared to serum androgen measurement and transvaginal/transabdominal ultrasound.

Data sources: A systematic literature review and meta-analysis were conducted. Electronic and manual searches were carried out in the Cochrane Library, Embase, LILACS, PubMed, Scopus, Web of Science, and Google Scholar databases.

Study eligibility criteria: Studies conducted in humans, published in any language up to August 2023 and addressing the following research question were included: "Can serum anti-Mullerian hormone levels be used as a diagnostic marker of PCOS in comparison to serum androgen levels and transvaginal/transabdominal ultrasound?". Furthermore, only articles that used the Rotterdam (2003) criteria, the National Institutes of Health of 1990 criteria, the Androgen Excess and PCOS Society criteria, or the Evidence-based Guidelines on PCOS from 2013, 2018, and 2023 for diagnosing women with PCOS were included.

Study appraisal and synthesis methods: Two independent reviewers selected the studies, and extracted and analyzed the data. The QUADAS-2 and GRADE tools were used to analyze the risk of bias and certainty of evidence.

Results: This systematic review included 45 studies. The studies exhibited a low risk of bias in the "Reference standard" and "Flow and time" domains but showed a moderate risk of bias in the "Patient selection" domain and a high risk of bias in the "Index test" domain. The meta-analysis of the case-control studies demonstrated a sensitivity of 81% and specificity of 82%, whereas the meta-analysis of the cross-sectional studies showed a sensitivity of 80% and specificity of 85%, both with 95% confidence intervals. The certainty of the evidence was rated as "low".

Conclusions: This systematic review showed that serum anti-Müllerian hormone levels can serve as a diagnostic marker for PCOS, when factors like age, test standardization, PCOS phenotypes, and body mass index are considered. Otherwise, the anti-Müllerian hormone should be used as an adjuvant to the PCOS diagnostic criteria established through consensus and/or guidelines. Additionally, serum concentrations reflected the severity of this syndrome.

Objective: Body image (a woman's perceptions and attitudes about her body) likely plays a role in pelvic organ prolapse treatment satisfaction and post-operative sexual function. The primary aim of this study was to describe changes in body image after surgical repair of vaginal vault prolapse. The secondary aim was to evaluate whether changes in sexual function are correlated with changes in body image.

Methods: This was a planned secondary analysis of a randomized three-arm trial comparing surgical approaches for vaginal vault prolapse. Women with symptomatic post-hysterectomy vault prolapse were randomized to: transvaginal native tissue repair (NTR), mesh placed abdominally (Sacrocolpopexy; SC), or mesh placed transvaginally (TVM). Body image was measured using the validated Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire at baseline, 6-, 12-, 24- and 36-months. Sexual activity and function were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA revised (PISQ-IR) at similar time points. Longitudinal analysis for changes from baseline in mean BIPOP score and the proportion of women who met a distribution-based estimate of the minimally important difference (MID) was performed using general mixed models for repeated measures. The same method was used as a model to predict change in sexual function based on body image.

Results: A total of 335 women were included in the analysis: NTR =123, SC=107, TVM = 105. Mean age was 66.1±8.5 years and a majority (242, 72%) had Stage 3 prolapse. Baseline total and subscale BIPOP scores were not significantly different by treatment arm. All arms improved by 6-months, and this improvement was sustained to 36-months with no significant differences between the groups for change in BIPOP score nor MID-equivalent improvement. 99(30%) women reported being sexually active at all visits, 131(39%) reported they were not sexually active at all visits, and the remainder changed sexual activity status throughout the study. Amongst sexually active participants, there were no baseline differences in PISQ-IR scores between groups (NTR, 54 women, 3.2+0.7; SC, 43 women, 3.3+0.7; TVM, 46 women, 3.1+0.6). In sexually active women, change in BIPOP and PISQ-IR scores were correlated at each visit and a significant association between these measures (p<0.001) remained after adjustment for baseline sexual function, site, age, surgical treatment arm, and baseline dyspareunia.

Conclusions: Body image improves following repair of vaginal vault prolapse, regardless of the surgical approach. Improvements in body image and sexual function are positively correlated among sexually active women.

Intrauterine devices are highly effective, long-acting, reversible forms of contraception. Despite their benefits, limited uptake persists, particularly among underserved populations, adolescents, and young adults. While most intrauterine device placement procedures are uncomplicated, pain is commonly reported, with more severe pain reported in certain groups. No current standard of care has been established specifically to manage pain with intrauterine device placement, resulting in wide variation in clinical practice. This article aims to provide practical, evidence-based, and expert-informed guidelines for managing pain during intrauterine device placement. The authors (a group of board-certified obstetrician-gynecologists, pediatricians, and a family physician) conducted a virtual expert meeting to develop consensus-based recommendations for pain management. The meeting covered environmental considerations, non-pharmacological, and pharmacological options. Key strategies include using a person-centered care model that focuses on patient values, needs, and preferences to promote shared decision-making around pain relief. Clinicians should assist patients in setting realistic expectations, including a discussion of the placement procedure, anticipated pain, and all options for pain relief, to allow for a comprehensive informed consent process. Non-pharmacological interventions, such as the use of therapeutic language and comforting environmental, complementary and integrative, and mind-body elements, are recommended to reduce patient anxiety and discomfort. In terms of pharmacological options, clinicians may offer pre-procedural specific nonsteroidal anti-inflammatory drugs (e.g., naproxen and ketorolac) and anxiolytics to patients with significant anxiety, as well as intra-procedural application of topical anesthesia and paracervical or intracervical blocks. Finally, additional techniques, such as using appropriately sized instruments and ensuring gradual and gentle procedural steps, can also help enhance patient comfort during insertion. These expert guidelines emphasize the importance of personalized, trauma-informed, and evidence-based care, prioritizing patient autonomy and preferences to facilitate a safe and acceptable insertion experience. They are critical to reducing barriers to intrauterine device uptake and improving overall patient outcomes.

Background: Postpartum hemorrhage is the most common complication in obstetrics and is a leading cause of serious maternal morbidity. Women with one previous cesarean delivery are at risk for postpartum hemorrhage.

Objective: The aim of this study was to compare the risk of postpartum hemorrhage according to the planned mode of delivery among women with one previous cesarean delivery.

Study design: This study was a secondary analysis of the Lower Uterine Segment Trial. The primary outcome was postpartum hemorrhage, and the secondary outcome was a composite of severe postpartum hemorrhage including the need for blood transfusion, second-line therapy to stop bleeding, or hysterectomy. The exposure was the planned mode of delivery, which was decided at around 36 weeks of gestation. Multivariate logistic regression analysis with a random intercept of the maternity unit was used to assess the relationship between the planned mode of delivery and postpartum hemorrhage. A secondary analysis using inverse probability weighting was performed to limit indication bias.

Results: Of the 2948 women included in the Lower Uterine Segment Trial, 2889 women were included in this secondary analysis; 2689 (93.0%) chose planned vaginal delivery, and 200 (7.0%) planned cesarean delivery. The rate of postpartum hemorrhage was lower in the planned cesarean delivery group than in the planned vaginal delivery group (2.5% vs 7.5%, adjusted odds ratio 0.28 [0.11-0.69] P<.01). The rate of the composite maternal outcome of severe postpartum hemorrhage was similar between the 2 groups (2.9% vs 2.0%, adjusted odds ratio 0.66 [0.24-1.83] P=.42). These results were consistent in the secondary analysis involving inverse probability weighting (odds ratio 0.35 [0.24-0.51] P<.01).

Conclusion: Planned cesarean delivery was associated with a lower percentage of women with postpartum hemorrhage compared with planned vaginal delivery after one previous cesarean delivery. However, the use of transfusion, second-line therapies, or hysterectomy was rare, and the rates were similar between the 2 groups.